Marginal ulceration after Roux-en-Y gastric bypass - literature review and management algorithm

Abstract

Roux-en-Y gastric bypass (RYGB)-associated marginal ulceration (MU) poses significant challenges for both patients and clinicians. Persistent symptoms such as epigastric pain, nausea, and reduced oral intake complicate the clinical landscape. MU can lead to severe complications, including anastomotic strictures, bleeding, and perforations. The etiology of MU is intricate, likely stemming from a combination of technical and patient-related factors. Technical considerations involve ischemia, tension on the anastomosis causing tissue ischemia, anastomotic technique, gastric pouch size, foreign bodies, and gastrogastric fistulas. Patient factors encompass smoking, nonsteroidal anti-inflammatory drugs (NSAIDs), Helicobacter pylori (H. pylori), and uncontrolled medical comorbidities. Diagnosis primarily relies on upper endoscopy. Initial treatment typically involves proton pump inhibitors (PPI) and sucralfate. Should these measures prove insufficient, the addition of misoprostol and the implementation of endoscopic techniques, such as oversewing or stenting across the ulcer, may be considered to facilitate healing. Ultimately, if medical and endoscopic interventions fail, surgical options become imperative. These include transthoracic truncal vagotomy and revisional procedures such as resection of the ulcer with redo gastrojejunal anastomosis, resection of the ulcer and pouch with esophagojejunal anastomosis, or resection and reversal to normal anatomy. Surgical interventions demand expertise and should be conducted at qualified, high-volume centers. To support clinicians in comprehending the nuances of MU, we conducted a literature review, presenting a summary of our findings. Additionally, we propose an algorithm delineating the escalation of treatments for MU, ranging from medical to endoscopic to surgical therapies. This concise review aims to assist clinicians in both the prevention and treatment of marginal ulceration.